Scale up of Services for Mental Health in Low-‐Income and Middle

Scale up of services for mental health in low-income PRIME Policy Brief 2 May 2013 and middle-income countries Julian Eaton, Layla McCay, Maya Semrau, Sudipto Chatterjee, Florence Baingana, Ricardo Araya, Christina Ntulo, Graham Thornicroft, Shekhar Saxena

SUMMARY

There is a well-documented gap between mental health needs and available care, and a strong moral and economic case for investing in services to close this gap. However, while there is now a strong evidence- base, for there to be a significant global impact, mental health initiatives need to be planned and developed in a strategic way that will enable significant scaling up of services.

• Mental illness represents one of the highest burden of all disease, and is a major factor in perpetuating poverty. Currently, around 80% of people in low-income countries do not receive treatment that would effectively reduce impairment.

• There are many diverse examples of mental health programmes offering services, including in Low and Middle-Income Countries (LAMICs), but although many are doing good work, few are evaluated, remaining hidden from view.

• Although a sound evidence base now exists, and new resources are available, this is not yet being accessed by service implementers.

The findings propose the scaling up of mental health services in

an inclusive, systematic and strategic manner that requires strong advocacy for financial commitment.

PRIME’s goals are to:

(1) Develop evidence on the implementation & scaling-up of mental health treatment in primary & maternal health care, in low resource settings

(2) Enhance the uptake of its research evidence amongst key policy partners and relevant stakeholders

programme for improving mental health care Evidence on scaling-up mental health services for development

Funding

Development assistance in health has grown. Despite the mental health treatment gap, 1 less progress has been made for mental, neurological and substance abuse disorders Political will and the prioritisation of health At the core of global, and national efforts to scale up services is the need for decision makers and political leaders to understand the issues, recognise their importance, and prioritise action to address mental health needs. A survey of national mental health experts in 59 countries showed improvements in the awareness of mental health issues amongst leaders, although as many as 26 countries identified continuing poor awareness and low priority or poor commitment by political leaders as major barriers to development of mental health services.

“ There is a lack of political will to provide a workable mental health policy, introduce reforms in health service delivery, and poor funding at all levels of government. ” – Principal, School of Psychiatric Nursing, Nigeria

Organisation of services Existing structures into which mental health services fit often do not facilitate evidence-based interventions. The continued dominance of large psychiatric hospitals in many countries is at odds with the evidence, which suggests that most services should be delivered in decentralised locations, with deinstitutionalisation, and integration between the community and hospitals, and appropriate referral systems incorporating secondary and tertiary care. There still remains an important role for tertiary hospitals in provision of specialised beds, which remain in short supply compared with need.

Results from a global survey indicate that the ingredients for successfully scaling up are:

SUSTAINABLE PROVISION OF INTEGRATION OF ESSENTIAL DRUGS & ONGOING TRAINING & MENTAL HEALTH CARE SUPERVISION PSYCHOTHERAPY into mainstream systems, by mental health care services for people with to strengthen health specialists to monitor and long-term (chronic) systems and equip trained motivate district and primary conditions, social care personnel to carry out health care staff and education evidence-based care

COMMUNITY BASED CARE AND TASK SHARING INTEGRATING MENTAL HEALTH INTO HEALTH INFORMATION SYSTEMS to empower families, carers and volunteers to support people with mental illness, and reform service structures to to show demand for services, ensure the allow a wider range of staff to provide mental health care mobilisation of essential drug supplies and increase recognition of this sector

Most agree that evaluation is important, however, only 20% of community-based mental health programmes in Africa were evaluated. Amongst those that reported evaluating mental health programmes, only 39% reported to have been completed.

There were many gaps in metrics and evaluation, with inadequate and incomparable primary

data available. Well-researched pilot projects are rarely scaled-up.

C lose collaboration between research groups, government, non-governmental organisations and other stakeholders is essential from the outset

Consideration of practical sustainability issues is vital for making services research influential in the real world. FUNDING FOR MENTAL HEALTH

FINANCIAL RESOURCES STAFF TRAINING Gaps in metrics and evaluation, Inadequate and incomparable primary data sources/analyses • To scale up services, more resources are • In most LMIC, the ratio of people who need mental health care to the number of qualified psychiatrists is so disproportionate that Well researched pilot projects are rarely scaled-up. needed, and existing resources need to be psychiatrists will never be able to deliver the care needed in the used more efficiently foreseeable future. Supporting general doctors and nurses to provide most of the clinical care is therefore essential (task • Absence of funding is believed to be a sharing). major barrier to programme • Training is an essential component of any effort to scale up implementation Mental health interventions are associated with improved economic outcomes. Of the 19 associations services. Such training must be tailored to the roles staff will play in practice (for example in a reformed task sharing model of tested, ten showed the intervention to have a significant positive effect on economic status, and nine a • Tracking of financial resource allocation is services). Any training must always take place in a planned way, non-significant positive effect (or no tests of significance were provided). one way to judge political commitment to where those trained are able to use their new knowledge and skills scaling up of mental health services in an environment that supports them, for example where there is time and space for them to work, where they have medication and any equipment that they need, and most importantly, where they • Brazil and Chile are two examples where can receive regular supervision. increased allocation of funds have been achieved • Shortage of skills among mental health leaders is a major barrier to progress in mental health service reform. Good new training • There is evidence that more funds are materials now exist to build capacity at all levels of the health system. likely to be available from international sources in future • Training options have emerged to address the need for leadership and public health skills among mental health professionals. Image: Microsoft Clipart Photo: Julian Eaton

Image: Microsoft Clipart EVIDENCE-BASED INFORMATION

• Several guidelines were identified to assist scale up of services.

• Some covered inter-sectoral mental health interventions (e.g. WHO Community-Based Rehabilitation Guidelines 1), whilst others related to a specific mental health work (e.g. in humanitarian settings 2).

• The PLoS Medicine global mental health series 3 describes how non- specialist health workers can deliver effective treatments for mental and neurological disorders in resource poor settings, and how to integrate into primary care settings with treatment of other chronic disorders

• The WHO mhGAP Intervention Guide 4, published in Oct 2010, recommends interventions that aim to be feasible and acceptable in LMIC, for integrating into existing health systems. The Guide covers 8 priority mental, neurological and substance misuse disorders in non-specialised health settings.

• Full mhGAP training materials are also available 4. • Percentage of national health budgets allocated to mental health • Number of primary care workers trained in detection and management of common mental disorders • Population coverage of evidence-based mental health interventions within a human rights framework Specific interventions to increase coverage of Policy recommendations mental health services need to be part of a broader and integrated process, which will require POLITICAL strong advocacy for financial commitment, and WILL that important elements of health infrastructure are strengthened for service sustainability in the long term. TASK A high proportion of the need can be met with SHARING simple packages of care delivered in non-hospital settings by non-specialists. Services should be both evidence-based and locally relevant. Photo: BasicNeeds Specialist mental health staff are required at the district level, with at least a prescribing clinician. This can then be a point of referral and supervision Besides being traditional clinicians, mental health DISTRICT LEVEL for primary care services. specialists need to accept responsibility for planning, training, supervision and advocating with Scaled up services need to be evaluated, and the decision makers in their area of expertise. To EVALUATION lessons learnt generalized. The evaluation of achieve this goal, specialists need access to relevant innovative programmes can make an important training in these skills. BROADENING SKILLS contribution to the case for scaling up. Photo: Julian Eaton Resources 1. WHO Community-based Rehabilitation Guidelines (2010). Available http://www.who.int/disabilities/cbr/guidelines/en/ 2. IASC Guidelines on Mental Health and Psychosocial support in Emergency settings. Available http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf 3. PLoS Medicine Global Mental Health Series (2012). Available http://www.plosmedicine.org/article/browse/issue/info%3Adoi%2F10.1371%2Fissue.pmed.v09.i05;jsessionid=3C1650083B30558 877F2FB3190B4469A 4. WHO mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialised health settings (2010). Available http://www.who.int/mental_health/evidence/mhGAP_intervention_guide/en/

Policy brief based on published research by Eaton J, McCay L, Semrau M, Chatterjee S, Baingana F, Araya R, Ntulo C, Thornicro ft G, Saxena, S (2011). Title Scaling up of services for mental health in low-income and middle-income countries. Journal Lancet 2011; 378:1592-1603

About PRIME is a Research Programme Consortium (RPC) led by the Centre for Public Mental Health at the University of Cape Town (South Africa), and funded by the UK government’s Department for International Development (UKAID). The programme aims to develop world-class research evidence on the implementation, and scaling-up of treatment programmes for priority mental disorders in primary and maternal health care contexts, in low resource settings.

Partners and collaborators include the World Health Organization (WHO), the Centre for Global Mental Health (incorporating London School of Hygiene & Tropical Medicine and King’s Health Partners, UK), Ministries of Health and research institutions in Ethiopia (Addis Ababa University), India (Public Health Foundation of India), Nepal (TPO Nepal), South Africa (University of Kwazulu-Natal & Human Sciences Research Council) and Uganda (Makerere University & Butabika Hospital); and international NGOs such as BasicNeeds, Healthnet TPO and Sangath.

PRogramme for Improving Mental health carE (PRIME) Alan J Flisher Centre for Public Mental Health Department of Psychiatry & Mental Health University of Cape Town 46 Sawkins Road, Rondebosch, South Africa 7700

Web: www.prime.uct.ac.za Policy brief design and layout: Amit Makan This document is an output from a project funded by UK Aid from the Department for International Development (DFID) for the benefit of developing countries. However, the views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.